Manager, Hospital Bill Audit & Itemized Bill Review (Program Integrity)
Hybrid · Miami, Florida, United States or Atlanta, Georgia, United States
Job Summary
Manager, Hospital Bill Audit & Itemized Bill Review (Program Integrity) leads strategy, execution, and continuous improvement of hospital claim audits and itemized bill review functions within the Program Integrity organization. Oversees a team of auditors/reviewers, develops SOPs, quality controls, and escalation pathways; manages workflow intake, prioritization, and turnaround commitments; ensures proper application of payer policies, CMS guidelines, state/federal regulations, and provider contract terms; directs investigation of waste, abuse, or fraud indicators; collaborates with analytics to identify outliers and risks; translates audit results into initiatives (edit development, provider education, contract language recommendations, process improvements); monitors recoveries and appeal outcomes; owns QA for audit determinations and documentation; oversees audit summaries, demand letters, and appeal packages; ensures regulatory compliance and HIPAA/privacy; may oversee vendor oversight. Requires BA/BS and 5+ years in related fields; nursing degree and RHIA/RHIT/CHC/CPC preferred; ability to lead and develop teams; strong analytical and communication skills.
Required Qualifications
- Requires BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience providing an equivalent background.
- Preferred Certifications: CHC, CPC, RHIA/RHIT (any relevant).
- Experience with payment integrity platforms, claims editing logic, or audit workflow tools preferred.
- Experience supporting appeal defense and provider dispute resolution preferred.
- Familiarity with federal and state program integrity frameworks (Medicare/Medicaid) preferred.
- Experience in hospital billing, facility claims auditing, payment integrity, or revenue integrity, including itemized bill review preferred.
- People management or team lead experience preferred.
- Strong documentation, analytical, and decision-making skills; ability to produce defensible audit findings preferred.
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